Illustration by Polly Becker

Before she showed up at Duke's Morreene Road Pain Clinic last year, Christy Anderson had suffered through intense migraines for more than three decades. They hunkered down in her forehead for days at a time, making her feel as if someone had planted a suction machine behind her eyebrows. During the worst attacks, all the forty-six-year-old Anderson could do was lie in the dark, motionless, hoping not to throw up. Raising her two children became an exhausting burden. "When they wanted to play tennis or kick the soccer ball, or they wanted me to go to a school play, it was very difficult for me to drive a car," she says. The most workaday tasks, such as showering, became challenges. "Even the water hitting your head hurts," she says.

"It makes you so sad, because you want to enjoy your life and you can't participate."

Anything could trigger a migraine for Anderson: certain smells, not enough sleep, changes in barometric pressure, the approach of menstruation. Nothing seemed to help. Anderson tried the painkiller Vicodin and the injectable migraine medication Imitrex. They provided some respite, she says, "but I didn't find any long-term relief."

By the time she arrived at Duke, Anderson was in good company. According to the American Medical Association, 75 million people in the United States suffer from chronic pain, often severe enough to warrant medical attention. Many travel from doctor to doctor, never getting complete relief. The result is what some experts call an "epidemic" of untreated pain, similar to other noninfectious disease epidemics.

"Chronic pain is a medical problem—like diabetes, like heart failure, like chronic obstructive lung disease—and it needs to be managed," says Christine Miaskowski, a past president of the American Pain Society. "We don't have a health-care system that's equipped for that. If a person doesn't get better after two Vicodin, most primary-care doctors don't know how to deal with it."

The results of this inattention can be disastrous. Left to fester, pain can lead to obesity, depression, insomnia, even immunosuppression. Research suggests that chronic pain triggers abnormalities in the brain and spinal cord and worsens the prognoses of cancer patients. "Treating pain is not just a compassionate exercise for quality of life. It's essential for health," says Scott Fishman, past president of the American Academy of Pain Medicine.

In recent years, the medical profession has turned its attention to understanding pain on a deeper level and to developing innovative therapies for patients like Anderson. Across Duke's campus, from the anaesthesiology department to the Divinity School, physicians are crossing disciplines in search of new approaches to pain management. Some of the research involves biological fixes such as concentrated salt injections and topical creams. The most interesting work, however, acknowledges that pain is more than a one-dimensional condition—it also involves the mind, the spirit, and the social context.

That's why some doctors are experimenting with stress-reduction techniques such as relaxation skills and guided imagery; probing the links between pain and seemingly unconnected issues like parental substance abuse; and exploring the role of faith communities in increasing access to pain care. "We are on the verge of unprecedented research that will put Duke on the forefront, in ways we have never seen before," says Winston Parris, chief of Duke's Division of Pain Management, under whose umbrella some of the researchers work.

What remains to be seen, though, is whether the medical profession as a whole will start treating pain as seriously as it treats other diseases—particularly in a regulatory climate that sometimes punishes doctors for practicing aggressive medicine.

Until recently, when it came to pain, many physicians adhered to a rather simplistic scientific model. "The way pain has been traditionally understood has been using the notion of a simple ‘pain pathway,'" says Duke psychiatry professor Frank Keefe, a world-renowned pain expert. In this model, signals travel from the injury site along a series of nerve fibers until they reach the brain. "This is a model that, back to Descartes, has been used to explain pain," Keefe says. "The problem is that it often doesn't work."

During World War II, seriously injured soldiers on Italy's Anzio beachhead reported far less pain than civilians who had undergone surgery in U.S. hospitals. Harvard anaesthesiologist Henry Knowles Beecher, who observed this as an Army medical consultant, concluded that the joy of survival and the prospect of leaving the battlefield often masked the pain of the injury itself. Pain, Beecher later wrote, was "complex, subjective, and different for each individual."

"You don't have to go to Anzio to see this," Keefe says. Subsequent studies have shown that doctors can rarely predict the intensity of a patient's suffering from the severity of the injury. Keefe, like many of his colleagues, now believes pain is mediated by both thoughts and emotions, which can actually close "gates" in the neural pathways, blocking unpleasant sensations. His own work focuses on using the brain to control pain. In one experiment, he taught a group of osteoarthritis patients coping skills such as relaxation, imagery, and calming self-statements—and discovered significant drops in both pain and psychological disability. "We believe these treatments alter how the brain processes pain signals," says Keefe, who is now studying patients with non-cardiac chest pain, various cancers, and chronic low-back pain.

Keefe doesn't work in a vacuum. Over the past twenty years, researchers have become more sophisticated in examining the neurobiological mechanisms underlying different types of pain. Likewise, clinicians have developed bolder and more-nuanced treatment strategies. Many of the nation's top-ranked hospitals have opened facilities devoted specifically to pain management—including Duke, which in 2000 pulled together neurologists, anaesthesiologists, psychiatrists, psychologists, physical therapists, and neurosurgeons to create the multidisciplinary clinic on Morreene Road near the hospital.

In this changing national climate, pioneers like Keefe have paved the way for the next generation of researchers, including assistant clinical professor of psychiatry and hematology Christopher L. Edwards A.H.C. '97, who is exploring the complex ways pain interconnects with brain chemistry, social networks, emotions, money, diet, genetics, and even faith.